Enclosed is my/our remittance for The Arc of Iroquois County Membership dues in the amount of $15.00 US.  Membership is considered as family (Mr. & Mrs.) unless otherwise specified.

__ Mr.
__ Ms.
__ Mr. & Mrs.

        Name _________________________________________________

        Address _______________________________________________

        City, State, Zip __________________________________________

        Telephone Number (Optional) ______________________________

        Email Address (Optional) __________________________________

PLEASE COMPLETE ALL THAT APPLY:

Your Age Group:            Your relationship to disabled person (if applicable)

__ 1-24                            __ Parent of _______________________
__ 25-34                          __ Guardian of _____________________
__ 35-44                          __ Relative of  _____________________
__ 45-54                               Relationship ____________________
__ 55-65                               (sister, brother, aunt, uncle, friend, other)
__ 66+                                   Age of disabled person ____________
                                         __ Employee of The Arc

PLEASE INDICATE YOUR CHOICE:

__ Mail from The Arc of Iroquois County, State, and National

__ Mail from The Arc of Iroquois County only